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准父母A 基本信息

请尽量用英文填写,首先填写准母亲的信息
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中间名
中间名 (如适用)
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电子邮箱
电子邮箱
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联系电话
联系电话
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家庭地址
家庭地址
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城市
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省份/州
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邮编
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出生日期
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年龄
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您的工作单位及职业:
e.g. Manager with Google Inc
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您的国籍
China/USA
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族裔
Asian/White/Hispanic
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宗教信仰
Your Religion Preference
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您的业余兴趣爱好是什么?
e.g. Hiking, Music
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您的健康状况总体而言如何?
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您是否有值得注意的健康问题,如有请说明
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您是否抽烟?如有,频率和量如何
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是否使用酒精饮料?如有,频率和量如何
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您是否使用毒品?
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您是否曾被判有罪?
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您是否曾因精神问题住院或寻求医学帮助?
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婚姻状态
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您希望把谁的名字写在孩子的出生纸上?您是否和其他人共享孩子的监护权?
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如选择“其他”,请详细说明
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关于婚姻状态的更多信息
Years together if living with a partner; Year getting married; Year getting divorced if applicable.
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准父母B 基本信息

如婚姻状态为单身,请跳过此部分,直接点击“下一步”
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中间名
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Last
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电子邮箱
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联系电话
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是否与准父母1的家庭住址一致?
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家庭地址
Street Address
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城市
City
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所在省份
Province/State
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邮政编码
Zip Code
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国家
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出生日期
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年龄
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您的工作单位及职业:
e.g. Manager with Google Inc
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您的国籍
China/USA
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您的族裔是?
例如:亚裔/西裔/非裔
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您的宗教信仰是(如适用)?
如无宗教信仰请写“无”
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您的业余兴趣爱好是什么?
e.g. Hiking, Music
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您的健康状况总体而言如何?
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您是否抽烟?如有,频率和量如何
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是否使用酒精饮料?如有,频率和量如何
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您是否使用毒品?
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您是否曾被判有罪?
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您是否曾因精神问题住院或寻求医学帮助?
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准父母共同信息

如您非单身或同性,您寻求辅助生殖的原因是什么?
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是否在准备实施代孕或捐卵之前,向不孕不育方面的专业人士进行过医学和心理学方面的评估?如有,请说明
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您是否准备以及为什么选择使用代孕
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您是否有其他子女?请加以说明。
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如为是,您希望要更多小孩的原因是什么?
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如为是,您是否已经告诉他(们)准备再要小孩的计划?他们是否支持?
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包括您在内,家中有几口人 ,分别为:
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您目前使用的试管婴儿机构的名字及地点
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您的主治医师名字
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试管婴儿诊所的主管护士或客户经理的联系方式?
(如电话、邮箱、Wechat)
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如您已经有冷冻胚胎,目前共有几颗?
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如您还没有冷冻胚胎,现在处于什么阶段?预计多久可以准备好?
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您是否使用或计划使用捐卵/捐精?
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您的代孕计划是否得到家人的支持?
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您是否会顾虑到人们对于您使用代孕的看法?如有顾虑,原因是什么
If yes, please explain.
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您是否知晓您的代母需要进行至少两次旅行,诊所会要求1-2天的时间进行医学检查,3-4天的时间进行胚胎移植
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您是否知晓您可能需要在进入合同前接受心理评估?
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在胚胎发育过程中诊断有异常高风险时,您是否考虑进行妊娠中止?请进一步说明。
Elaborate, if you choose no.
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您是否愿意接受犯罪背景调查?
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如您的胚胎未能成功受孕,您是否计划培育更多胚胎?
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您计划每次周期移植几个胚胎?
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在代母怀孕期间,您希望和代母保持何种程度的联系?
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在宝宝出生以后,您希望和代母保持何种程度的联系?
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您是否需要代母提供母乳喂养?
注:大多数客户会选择奶粉或水奶喂养而不是母乳
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您会怎样向孩子谈论代母? 您是否预期未来孩子会和代母见面?
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您对于选择代母是否有具体要求?
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在代母怀孕期间,您对代母是否有特别要求?请说明
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如果您想对未来的代母说些什么,请在下面写上几句话。
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在您和您的配偶未来意外身故的情况下,请指定一位紧急监护人
例如您的直系亲属,填写其名字及联系信息
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当前家庭年收入
此项信息仅在本公司档案留存,不会披露给代母或其他第三方
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本人声明以上信息均真实有效。
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请上传您和家人的照片(2-3张)
Upload your pictures...
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准父母1 签字
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准父母2 签字 (如适用)
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